Joint Pain differential

Breaking down the Joint Pain differential

1. Is it really arthritis?
· Periarticular: bursa, fascia, tendon, ligament, epicondyle, myofacial pain/fibromyalgia
◦ Bursitis – usually only painful with palpation
◦ Tendonitis – usually pain with active or resisted motion
◦ Arthritis – usually pain with passive motion, as opposed to soft tissue problem don't usually hurt with passive motion
· Non-articular: nerve entrapment, bone tumor, vasculopathy, etc.

2. Acute or chronic?
· Acute < 8 weeks – gout, viruses (parvovirus), serum sickness often self-limited
3. Inflammatory or not?

	Inflammatory (Infectious, Gout/crystals, Psoriatic, RA, SLE, Viruses)	Non-inflammatory (OA)
AM stiffness	>30 min	<15 min
With rest	More stiff	Relief of pain
With use/exercise	Relief of pain	Worsening of pain
Synovial fluid	>2000 cells (mostly PMNs)	<2000 cells

*Fibromyalgia – AM stiffness, pain with use and at night, polyarticular pain w/ myalgias, tender pts

4. Pattern of Joint involvement

	Inflammatory	Non-inflammatory
Monoarthritis	ID – Gonnorhea, bacterial, TB, fungal, Lyme disease Crystals – Gout (monosodium urate), pseudogout Hemarthrosis Pauciarticular juvenile RA Osteomyelitis	OA Trauma/fracture/osteochondritis dissecans Neoplastic Congenital hip dysplasia
Pauciarthritis (2-4 jts)	ID – Dis. Gonnorhea, Endocarditis Crystals – Gout, pseudogout	OA
Polyarthritis	ID- Parvovirus, HCV, Lyme disease Sarcoid Pseudogout (Calcium Pyrophospate Dihydrate Crystal Deposition Disease) Autoimmune – RA, SLE Spondyloarthropathy – Reactive arthritis (Formerly Reiter’s syndrome), Psoriatic, Ankylosing spondylitis, Inflammatory bowel disease associated arthritis	OA

· MCP/PIP = RA
· DIP/PIP = OA
· Symmetric = RA
· Asymmetric = Gout, Psoriatic, reactive arthritis

5. Systemic features?

Skin	Plaque, pitted nails – Psoriasis Malar rash – SLE Erythema nodosum – Sarcoid, Crohn's Pyoderma gangrenosum – IBD, SLE, RA, anklyosing spondylitis, sarcoid
Musculoskeletal	Heberden's nodes (DIP) - OA Boudard's nodes (PIP) - OA Boutonniere and swan neck deform – RA Dactylitis (sausage digits), bursitis, enthesitis - Spondyloarthropathies

6. Patient demographics?
Women – RA, SLE, fibromyalgia Younger – RA, SLE, reactive arthritis, spondyloarthopathies

Men – Gout, Spondyloarthropathy Older – OA, polymylagia rheumatica